Feeling Sad and Usless

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Clinical Rehabilitation 2010; 24: 555564

Feeling sad and useless: an investigation intopersonal acceptance of disability and its association with

depression following strokeEllen Townend, Deborah Tinson, Joseph Kwan and Michael Sharpe School of Molecular and Clinical Medicine,

University of Edinburgh with participants from The Western General Hospital, Edinburgh, Edinburgh, UK

Received 1st September 2009; returned for revisions 20th September 2009; revised manuscript accepted 28th October 2009.

Objectives: To study the association of acceptance of disability with depression

following stroke and its ability to predict depression at follow-up.Design: A prospective cohort mixed (quantitative and qualitative) design was used.

Setting and subjects: Patients admitted to a stroke unit were consecutively

recruited. Eighty-nine participated at one month and 81 were followed up nine

months post stroke.

Main measures: Depressive disorder was assessed using a structured clinical

interview. Disability and acceptance of disability were measured using self-report

scales. At one month post stroke, 60 consecutive participants also participated in

open-ended interviews exploring their individual concerns about having had a

stroke and their responses were analysed qualitatively.

Results: One-third of participants were found to have depression (29/89; 33% at

one month and 24/81; 30% at nine months). Non-acceptance of disability remained

associated with depression after controlling for age, gender, original stroke severityand current disability at one month (odds ratio (OR)1.27, 95% confidence interval

(CI) 1.091.47) and nine months (OR 1.46, 95% CI 1.221.75). Also,

non-acceptance of disability measured at one month independently predicted

depression measured at nine months (OR 1.19, 95% CI 1.051.35). The

qualitative findings illustrated a self-reproachful element to non-acceptance of

disability. Patients with depression often said that they should still be capable and

sometimes referred to themselves as useless; whereas patients who were not

depressed commonly reported having accepted stroke-related disability.

Conclusions: These finding suggest that personal beliefs about accepting disability

are associated with and predict emotional adaptation following stroke.

Introduction

We know that a third of people who havea stroke suffer from depression in the following

16 months,1 but we know relatively little aboutthe psychological causes and maintaining factorsof such depression. Although they have beenextensively studied, stroke lesion location andsize have not been well supported as major aetio-logical factors.2,3 While many studies have found apositive association between depression and phys-ical disability, the severity of disability has notadequately accounted for the occurrence of

Address for correspondence: Ellen Townend, NHS Fife,Department of Psychology, Stratheden Hospital, Stratheden,Cupar, Fife, KY15 5RR, UK. e-mail: [email protected]

The Author(s), 2010.Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/0269215509358934


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depression, leaving much of the varianceunexplained.3,4

The role of personal beliefs and values indepression after stroke has been relatively

neglected.5,6

Evidence from other populations sug-gests that individuals personal evaluations ofthemselves, their acceptance of their conditionand beliefs about their future may be associatedwith and maintain depression.7 Studies of strokehave examined personal beliefs about future recov-ery and found that individuals who report greaterhope, confidence and control regarding recoverytend to be less emotionally distressed.810 Manystroke patients, however, remain disabled tosome degree,1113 and the issue is then one ofadjusting to that disability. Acceptance of disabil-

ity theory highlights the importance of being ableto accept oneself as an intrinsically worthy persondespite having disability in achieving psychologi-cal adjustment.14,15

We aimed to study the association betweendepression and stroke patients acceptance oftheir disability. We hypothesized that lower accep-tance of disability would be associated withdepression and remain associated when strokeseverity, disability and demographic factors werecontrolled for.

Methods

Participants were NHS patients who had beenadmitted with a definite diagnosis of stroke tothe Western General Hospital, Edinburgh, a uni-versity hospital with a specialist stroke unit. Onlypatients who had survived one month and werefree of substantial cognitive impairment or aphasiawere included. This was ascertained largely bymeans of an initial medical assessment of stroke

severity that was routinely conducted on consecu-tive patients admitted with suspected stroke.Patients were selected from initial assessment ifthey: (a) had a definite stroke diagnosis and wereconsidered likely to survive; (b) were able tounderstand and respond sufficiently to give per-mission for subsequent contact. One hundredand twenty-one potential participants wererecruited and referred at this stage (we have

reported details of excluded participantspreviously16).

A further assessment was conducted one monthafter the stroke to verify exclusion of those with

substantial cognitive impairment or aphasiadefined by scores of (a) 7/10 on an abbreviatedcognitive screening test,17 and (b) 12/20 on thecomprehension and expression subsets of theFrenchay Aphasia Screening Test.18 Reasons fornon-participation at this one-month stage were asfollows: 1 had died, 1 had moved without leaving aforwarding address, 4 were too unwell, 18 failed thecognitive screen, 6 declined, and 2 were too dis-tressed to complete interviews. The final sampleconsisted of 89 participants of whom 22/89 (25%)had had a prior stroke (other details of stroke diag-

noses have been reported previously

16

).The local research ethics committee approvedthe study and all participants gave their writteninformed consent to participate. A research psy-chologist interviewed participants at home, or in aprivate room in the hospital. The one-month inter-view had two parts: (1) a structured interview thatyielded quantitative data that was conducted withall 89 participants and (2) a semi-structured inter-view that yielded qualitative data that was con-ducted with a subsample of 60 participants(participants 2180 inclusive). Recruitment forthe qualitative subsample was consecutive and itscommencement was delayed only until theresearch psychologist had completed her specialistinterview skills training. We chose a relativelylarge sample size and to avoid additional selectionof participants for the qualitative study to: captureenough participants with depression to compare tothose without; and to increase our confidence inmaking comparisons between the quantitative andqualitative findings via some quantification of thequalitative findings.19

Participants were followed up and had a repeatstructured interview that yielded quantitative dataat nine months post stroke. This was considered tobe a time by which most individuals recoverywould have peaked and they would have hadtime to reflect upon the impact of their stroke.Eighty-one of the original 89 participants werefollowed up at this time (2 had died, 4 were toounwell and 2 declined).

The structured interview comprised a structureddiagnostic interview for depression and verbal

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administration of self-report scales to measure dis-ability and personal beliefs about accepting dis-ability. Depressive symptoms were assessed withthe Structured Clinical Interview for the fourth

edition of the Diagnostic and Statistical Manualof the American Psychiatric Association(DSM-IV).20 Diagnoses of depressive disorderwere made by consensus between the research psy-chologist and her consultant psychiatrist supervi-sor (who was blind to the patients disabilitystatus). The final depression diagnosis was cate-gorized into: no depression, minor depressionand major depression according to DSM-IV.21

Stroke severity was measured with the NationalInstitute for Health Stroke Severity Scale forwhich scores may range from 0 to 36 and higher

scores indicate greater severity.

22

Disability inpersonal activities of daily living such as depen-dence in bathing was measured with a reversescored Barthel Index (Barthel ADL)23 for whichscores may range from 0 to 20. This was reversescored so higher scores indicated more disabilityand zero indicated independence.23 Disability inextended activities of daily living (e.g. writing aletter or travelling by bus) was measured with areverse scored Nottingham Extended Activities ofDaily Living Scale (Nottingham EADL).24

This was also reverse scored so that higher scoresindicated more disability and scores could rangefrom 0 to 21.

Non-acceptance of disability was assessed usingan adapted version of the eight-item Acceptanceof Illness Questionnaire.25 It was considered toaddress personal acceptance and adapted tostroke-related disability by substituting the wordillness with the effects of my stroke, or stroke(see Appendix). As items are all phrased to reflectself-devaluating beliefs about disability (seeAppendix) it is essentially a measure of non-acceptance of disability. Responses to items areLikert scaled and overall scores may range from0 to 32 with higher scores indicating a lower levelof acceptance.

Associations between depression (majoror minor) and other variables were examinedusing, t-tests or MannWhitney U-tests, and,Pearson or Spearman correlations, as appropriate.Logistic regression with depressive disorder asthe dependent variable was conducted to investi-gate the relative contribution of the variables.

Some multicollinearity between stroke severity,disability and non-acceptance of disability was tobe expected, therefore a conservative approach totesting for the independent contribution of

non-acceptance of disability was taken. At thefirst block, all the other variables were enteredsimultaneously, regardless of their univariate sig-nificance, in order to control for potential con-founding. Non-acceptance of disability was thenentered in the second block using the stepwise pro-cedure. We conducted analyses using SPSS forWindows version 13 (SPSS Inc., Chicago, IL,USA).

In their semi-structured interview, participantswere asked about their main concerns regardinghaving had a stroke using a semi-structured

format. Once topics of concern were established,further probe questions were used to elicitthoughts and feelings about these and other sub-sidiary issues. The interviewer ended interviews bysummarizing and checking what participants hadsaid. Qualitative interviews tended to take abouthalf an hour, they were audio-taped, transcribedand content-analysed using the Frameworksmethod.19

The research psychologist developed prelimi-nary codes (minor themes) via constant compari-sons or identification of theoretical concepts,which were grouped into frameworks (majorthemes). The consultant psychiatrist and clinicalpsychologist (who were blind to other data col-lected within the study) reviewed transcripts ofthe interviews and then they reviewed the prelim-inary codes identified by the research psychologist.New codes were developed, or existing ones mod-ified through further extensive discussion betweenthe research psychologist and clinical psychologistand pilot coding exercises using relevant data. Wewere attentive to patterns that may emergebetween beliefs and participant demographic orstroke characteristics, such as having had a priorstroke. The final coding scheme used producedgood consensus agreement between all three qual-itative analysts. We have previously reported ourfindings regarding fear of recurrence and beliefsabout prevention.16 The findings here relate tobeliefs participants expressed about their disabil-ities, related personal meanings and ways ofcoping with these. A secondary analysis was thenconducted taking depression status into account to

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study associations between depression and quali-tative concerns and these results are summarizedin the Results section.

Results

Quantitative results at one month post strokeParticipants mean age was 70.13 (11.29) years

and ranged from 32 to 90 years. The number ofmale participants (63/89 60%) was greater thanthat of females. Depressive disorder was diagnosedin a third (29/89; 33%) of participants, withapproximately equal proportions meeting criteriafor major depression (14/89; 16%) and minordepression (15/89; 17%). Five participants

reported currently taking antidepressants, whichhad been prescribed prior to stroke (three ofthese met criteria for major depression and twowere not depressed).

Age was not statistically significantly associatedwith depression; however, being female was (seeTable 1).

Stroke severity scores were relatively mild with amean of 4.48 (3.35) and it was not associated withdepression (Table 1). Barthel ADL scores sug-gested that most participants were only mildly dis-abled in personal ADLs and just over half of

participants (49/89; 55%) scored zero, indicatingfunctional independence.26 Nottingham EADLscores indicated a wide range of disability inextended daily activities and a slight bi-modalityin the distribution of scores was observed thatreflected more disability for outdoor than indoor

extended activities. Disability in both BarthelADLs and Nottingham EADLs was statisticallysignificantly associated with depression (Table 1).

Non-acceptance of disability scores were wide

ranging and normally distributed. Participantswith depression reported significantly highernon-acceptance than other participants and thesevariables were statistically significantly correlated(Table 1). They more often agreed with items 2, 3,4 and 6, indicating that they: had had a hard timeadjusting; missed doing things they had enjoyedpreviously; felt useless; and felt inadequate respec-tively. After adjustment for other variables in alogistic regression, non-acceptance of disabilityremained strongly and statistically significantlyassociated with depressive disorder (Table 2).

Table 1 Descriptive data for independent variables and their univariate and bivariate associations with major or minordepressive disorder one month post stroke (n89)

Variable (min to max score) Depressed(n29)

Not depressed(n60)

MannWhitney U,chi or t-test and

significance level

Pearson orSpearman correlation

and significance level

Age 70.38 (10.07) 70.02 (11.91) t0.15 0.881 0.15 0.888Gender (female) 17 (59%) 19 (32%) 5.897 0.021 0.26 0.015Stroke severity (036), median (range) 4 (118) 3 (014) U641 0.11 0.18 0.110Barthel ADLa (020), median (range) 1 (014) 0 (08) U602 0.01 0.27 0.009Nottingham EADLa (021), mean (SD) 10.7 (5.50) 6.4 (5.09) t3.63 0.001 0.36 0.001Lack of acceptance of disability (032),

mean (SD)17.3 (4.62) 11.5 (5.60) t4.88 0.001 0.46 0.001

aThese measures were reversed scored so that they reflected disability.

Table 2 Logistic regression at one month post stroke withmajor or minor depressive disorder as dependent variable(n89)

Oddsratio

Significancelevel

95% CI

Lower Upper

Age 0.984 0.519 0.929 1.042Gender 2.946 0.081 0.876 9.905Stroke severity 0.936 0.538 0.749 1.169

Barthel ADLa

1.151 0.452 0.798 1.661Nottingham EADLa 1.020 0.852 0.829 1.255Non-acceptance of

disability1.270 0.001 1.097 1.49

aThese measures were reversed scored so that theyreflected disability.

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Its addition to the model increased the hit-rate forcorrectly identifying whether or not participantswere depressed from 71% to 78% (with aby-chance hit-rate of 69%).

Quantitative results at nine months post-strokeAt the nine-month assessment, just under a

third of participants (24/81; 30%) were found tobe depressed with equal proportions of minor andmajor depression. Most (19/24; 79%) of these par-ticipants had been depressed at one month. Sevenparticipants now reported taking antidepressants(four met criteria for major and one for minordepression).

Depression was not bivariately associated withage, gender or stroke severity measured atnine-month follow-up. The associations betweendepression and Barthel ADL and NottinghamEADL disability at this time were not statisticallysignificant. Participants with depression were morepersonally non-acceptant of disability at ninemonths (mean for depressed was 19.04 (4.60), cf.mean for not depressed was 9.75 (5.81), t 6.96,P50.001) and this association remained highly sig-nificant after adjustment for the other variables(Table 3). Its addition to this model increased thehit-rate for correctly identifying whether or notparticipants were depressed from 71% to 87%

(with a by-chance hit-rate of 69%). Depression atnine months was also predicted by non-acceptanceof disability at one month but not by initial strokeseverity or disability at one month (Table 4).

Its addition to this model increased the hit-ratefor correctly identifying whether or not partici-pants were depressed from 70% to 76% (with aby-chance hit-rate of 69%).

Qualitative findingsParticipants often reported concern about their

disability and Being like this emerged as a majortheme for which feeling negative, or not was asubtheme. Ways of coping with both limitationsand the uncertainty of recovery were also voiced.In the secondary analysis that took depressiondiagnoses into account and applied basic quantifi-cation, patterns between qualitative themes anddepression status were found.

Feeling negative, or notMany participants reported feeling somewhat

sad (e.g. a wee bit disappointed) or frustrated(e.g. a bit cheesed off). Participants who weredepressed tended to describe stronger or darkerfeelings such as being trapped.

Once you have it, its like being in prison. I wonteven put a dog in prison. (P55, male, 66 years,depressed)

Damn this stroke and damn all this carry on.(P65, male, 42 years, depressed)

In contrast, nearly a third of participants, noneof whom were depressed, reported having no

Table 3 Logistic regression with major or minor depressivedisorder at nine months post stroke as dependent variableand independent variables measured at nine months poststroke (n81 participants)

Odds ratio Significancelevel

95% CI

Lower Upper

Age 0.973 0.481 0.900 1.051Gender 2.048 0.355 0.449 9.342Stroke severity 0.895 0.408 0.687 1.165Barthel ADLa 0.761 0.165 0.518 1.119Nottingham EADLa 1.031 0.790 0.825 1.287Non-acceptance of

disability1.457 0.001 1.216 1.746


Table 4 Logistic regression with major or minor depressivedisorder at ninemonths poststroke as dependent variable andindependent variables measured at one month post stroke(n81 participants)

Oddsratio

Significancelevel

95% CI

Lower Upper

Age 0.978 0.415 0.928 1.032Gender 1.644 0.383 0.538 5.018Stroke severity 1.008 0.943 0.801 1.269Barthel ADLa 0.909 0.549 0.667 1.240Nottingham EADLa 1.019 0.833 0.856 1.212Non-acceptance of

disability1.190 0.007 1.048 1.350




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concerns and a few pointed out that they were justnot worriers.

Im not concerned about anything. (P23, male, 71years, not depressed)I think that once you get to eighty years old thatunless youre the worrying type youre notsuddenly going to get depressed or sad. (P27,

female, 80 years, not depressed)

Being like thisOver two-thirds of participants reported some

Cant do issue as a main concern. Those fewpeople with more severe disability reported basicphysical issues (e.g. walking) as concerns. Othersreported concern about reduced day-to-day activ-

ities (such as grocery shopping, housework ordo-it-yourself); leisure pursuits (such as reading,writing, knitting, baking, golfing, bowling, bridgeor bingo); socializing with friends or family (suchas walking, shopping, driving, going to the pub ortheatre). A few reported being just too tired orrunning out of energy.

You sit here, you go to get up and you cant walk.(P71, female, 81 years, depressed)Ive started reading a book but only read 50 pagesso far, but I would have had it finished. I miss

that. (P36, female, 79 years, not depressed)Its the fact you cant get the energy to dothing . . . I just feel sleepy, Oh Im sleepy again.(P69, male, 65 years, not depressed)

Some used emotive language and metaphorsthat emphasized negative feelings about missingactivities.

Thats a bit disappointing and cuts you and youthink What can you do? Lifes got to carry on,but Ive been enjoying it [fishing] for 40 years.(P55, male, 66 years, depressed)

I was out in the car every day of my life, localshopping, the theatre, for meals . . . and now Imafraid thats taken a back seat . . . . Thats me, it

puts you out the picture for now. (P59, male, 75years, depressed)

Some participants suggested they should bestill able to carry out activities. They seemed tofeel morally obligated in household (such ashousework, DIY or paying bills) or caregiving

roles (such as looking after grandchildren orgiving lifts to wives or grandchildren).

All my life its [the housework] been I like it justso. Its not just so at the moment . . . Two timesnow my second cousin has come and done thehouse. I dont want to trouble her I dont wanther to make a habit of this. (P62, female, 86

years, depressed)As a result [wifes Menie`res disease] shes lostconfidence about going out on her own. I used totake her out and now I cant . . . . Well these are

just the thoughts of someone stuck in a chair whofeels they should be up doing things. (P58, male,80 years, depressed)

Nearly every participant who reported feeling

they should still be carrying out roles wasdepressed.

Negative personal meanings versus acceptance orefforts to accept disability

Participants often spoke about their capabilitiesas being not right, not as good, or less normal,whereas before they could do things without aseconds thought.

I cant grip my left hand normally and normaldaily life, for example, using a knife and fork

properly. (P59, male, 75 years, depressed)Reliance on others made some participants feel

helpless.

I dont like to ask . . . as Im very independent. Idont like to be beholden. (P62, female, 87 years,depressed)

Some even described themselves as useless.Their self-reproach often related to ideas thatthey should still be carrying out family or homeroles.

What on earth am I doing lying here [hospital]for when I could be doing something useful? (P59,male, 75 years, depressed)Id hate to think their life was looking aftertheir old man . . . . Its me who should be lookingafter them. (P64, male, 74 years, depressed)

In contrast, some participants appeared accept-ing. Some seemed to be helped by fatalistic beliefssuch as thats life and others argued that they had

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never really cared about certain activities and sodidnt mind their loss.

I feel a bit curtailed, but happy with my lot . . . notparticularly bothered, more acclimatized to it.(P67, male, 66 years, not depressed)Its a case of things are going to happen and youcant make alterations. Anything like, someone inlife has died, you cant do anything so theres no

point in being unhappy. (P61, male, 69 years, notdepressed)I werent that into it [bingo] it was just a placeto go. (P47, female, 82 years, not depressed)I dont miss it . . . Im quite happy in the house.(P73, female, 74 years, not depressed)

Many other participants reported various com-

pensatory ways of coping with their restrictions.They reported regarding restrictions as temporaryand so OK for now, or they focused on what theycould at least still do and perhaps did more of now,or how they still got things done in different ways.

Reading used to help pass the time . . . Ive gotsome reading glasses to come and hopefullytheyll be OK. I just accept it the now. (P47,

female, 82 years, not depressed)At least I can still walk, I just will never be able torun or kick a ball. (P54, male, 62 years, notdepressed)I felt rotten about getting someone in [to fix asliding door], but still pleased I was getting itdone. (P45, male, 76 years, not depressed)

Less common compensatory beliefs seemed toinvolve thinking how it could be worse, jokingabout problems, or reminiscing about what theydid do.

Ive had it lucky compared to some folk who cantdo a thing. (P63, female, 83 years, not depressed)At least my stroke has given us another talking

point, which is a change from hips etcetera! (P58,male, 80 years, depressed)Theres something of me in the countryside thatwouldnt be there apart from me [retired forestrycommissioner] . . . I still look back with pleasure,although I cant do. (P68, male, 88 years, notdepressed)

Participants with depression were more likely toreport objecting to reliance on others and much

more likely to report feeling useless about beingunable to carry out roles. Only participants whowere not depressed reported that they hadaccepted changes. Compensatory ways of coping

with restrictions were reported by participantswith and without depression.

Discussion

Depression was prevalent in the sample andaffected one in three participants at both oneand nine months following stroke. Disability wasonly weakly associated with depression; however,non-acceptance of disability was strongly asso-

ciated with depression in both qualitative andqualitative findings. The acceptance of disabilityscale, adapted for use in stroke, was sensitive toa range of personal reactions to disability fromhigh levels of acceptance to strongly negativeviews in which people endorsed comments thatthey felt inadequate and useless. Once initialstroke severity and current disability were con-trolled for, non-acceptance of disability remainedindependently associated with depression in multi-variate analyses.

The qualitative findings complemented theseresults. While many participants reported missingactivities, participants with depression expressedstronger thoughts and emotions of sadness andfrustration such as feeling/thinking of themselvesas trapped or helpless in relation to their depen-dence on others. Their accounts were oftenself-reproachful as they felt they should still beable to fulfil roles in their family or home, andthis seemed to be largely why they tended todescribe themselves as useless. The qualitativeanalysis also highlighted various ways participantstried to accept stroke-related restrictions (OK fornow, at least I still can, could be worse, joking,

did do). Some of those participants who were notdepressed seemed to have come to terms with theirdisability and often reported simply being notworried or having accepted their circumstances.

One strength of the study was the combinationof methods: qualitative interviews strengthenedthe quantitative findings and also offered furtherinsights.27 Evidence for the relevance of the accep-tance of disability measure in stroke was provided



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by the qualitative findings and this measure couldbe used in future quantitative stroke studies.Also, the use of face-to-face interviewing avoidedmissing/inaccurate data due to post-stroke or

age-related reading, visual or mild cognitiveimpairment. There were also weaknesses: first,participants may have biased their accounts oftheir situation toward what they perceive associally desirable responses. Second, althoughstroke severity was assessed by a clinician, disabil-ity was assessed only by self-report and someparticipants, particularly those who were notdepressed,28 may have underreported their disabil-ity. Finally, our results may also only be confi-dently generalized to stroke patients who havebeen admitted to hospital and who survived with-

out aphasia, or severe cognitive impairment.As far as we are aware this is the first study tohave investigated personal acceptance of disabilityamongst stroke patients. Previous studies havefound an association between acceptance of dis-ability and self-esteem among adults with a rangeof physical or mental disabilities,29 and betweenacceptance and distress among adults withacquired deafness.30 A small number of qualitativestudies of views of self after stroke have suggestedthat stroke profoundly disrupts patients sense oftheir bodies and personal identity.31,32 Our find-ings suggest that individuals vary substantially intheir personal adjustment to stroke-relateddisability.

Parallels may be drawn between some of thecompensatory strategies reported by our partici-pants and value change processes considered tofacilitate acceptance outlined by Dembo andWrights (1956) theory.14 Enlargement of thescope of values could include appreciating howone is relatively lucky (could be worse) or ableto accept change (thats life) if only because it isviewed as temporary (OK for now).Subordination of physique relative to othervalues (i.e. an enhanced appreciation of ones pos-itive unaffected characteristics and roles) could beapplied to participants ability to gain satisfactionwith what they at least still can do or did do.

According to the theory successful acceptance ofoneself involves Containing the effects of disabil-ity (i.e. to be able to mentally distinguish betweenfunctional losses and ones own self-worth). Mostparticipants appeared to have achieved this but

depressed individuals described themselves as use-less and reported thinking that they should stillbe capable of family or household roles. It is as ifthey derogated themselves as disabled persons

whereas others could distinguish the differencebetween their identity and disability. Dembo andcolleagues14 propose that the key to maintainingones own self-worth is to engage inTransformation from comparative values toasset values (i.e. to let go of unfavourable com-parisons with others or ones own past ability andto judge oneself in light of what one can realisti-cally do now). Participants who found differentways of enjoying themselves or getting thingsdone could be seen to have transformed theirviews successfully.

Our findings are also consistent with cognitivetheories of emotional adaptation that would pre-dict that, rather than disability per se, it is subjec-tive negative beliefs about oneself and onescondition (disability) that are most important indetermining emotional responses.7,33 One previousstudy into the cognitions about stroke also found astrong association between depression and nega-tive cognitions such as I feel inadequate and help-less.34 They also reported an inverse associationbetween two positive cognitions (Im optimisticabout the future, I feel I have a lot left to give)and depressive symptoms.

Our results support a strong associationbetween non-acceptance of ones disabled selfand depression. By nine months post stroke, therole of personal acceptance (or its lack) had astronger association with depression relative tostroke severity and disability that did not even cor-relate with depression in bivariate analyses. Also,depression at follow-up was statistically predictedby non-acceptance of disability at one month.Therefore, being unable to accept oneself asworthy in spite of ones disability appears to beemotionally detrimental both in the short andlonger term post stroke. However, these analysescannot conclusively establish the direction of cau-sation (i.e. whether not accepting ones disabledself caused depression or vice versa). Furtherresearch could aim to disentangle the direction ofsuch relationships.

Our findings suggest that for some patients itmight be important to address their personal beliefsabout disability when intervening to reduce

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depression following stroke. It would be interestingto study whether a successful reduction in depres-sion following intervention was accompanied by aconcordant increase in acceptance of disability.

A psychological approach to facilitating accep-tance of disability may involve eliciting and chal-lenging self-reprimanding thoughts of uselessnessand underlying should imperatives related topre-stroke roles and stroke-related disability.Some patients may also benefit from being encour-aged to consider adaptive compensatory beliefsabout unaffected abilities, characteristics androles such as those outlined by acceptance of dis-ability theory. Specialist psychological therapeuticexpertise would be required to implement theseclinical and research suggestions. Therefore, the

present lack of psychological support to strokeunits in Western countries3538 would need to bereversed.

Clinical messages

This study has found that depression follow-ing stroke is associated with patients senseof uselessness regarding their disabilities.

The acceptance of disability scale could beused as a brief valid measure of patients

sense of uselessness regarding theirdisabilities.

AcknowledgementsThe study was conducted as part of a UK MRC

studentship. We would like to thank our partici-pants, their clinicians and carers for theirparticipation.

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Appendix Acceptance of Disability Scale adapted for stroke

Stronglydisagree

Disagree Neutral Agree Stronglyagree

1) I have had a hard time adjusting to the limitations of my stroke 4 3 2 1 02) Because of the effects of my stroke I miss the things I like to do

most4 3 2 1 0

3) The effects of my stroke make me feel useless at times 4 3 2 1 04) The effects of my stroke make me more dependent on others than I

want to be4 3 2 1 0

5) The effects of my stroke make me a burden on my family and friends 4 3 2 1 06) The effects of my stroke make me feel inadequate 4 3 2 1 07) I will never be self-sufficient enough to make me happy 4 3 2 1 08) I think people are often uncomfortable being around me because of

the effects of my stroke4 3 2 1 0

564 E Townendet al.


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Feeling Sad and Usless

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